NEWYORK Department Sittin?l?um ofHeaHh ANDREW M. CUOMO HOWARD A. ZUCKER, M.D., J.D. SALLY DRESLIN, M.S., R.N. Governor Commissioner Executive Deputy Commissioner February 22, 2018 CERTIFIED MAIL-RETURN RECEIPT REQUESTED David D. Blasczak. M.D. Re: License No. 142005 Dear Dr. Blasczak: Enclosed is a copy of the New York State Board for Professional Medical Conduct (BPMC) Order No. 18-039. This order and any penalty provided therein goes into effect March 1, 2018. You are required to deliver your license and registration within 5 days of the effective date of the surrender provision to: clo Physician Monitoring Unit, NYS DOH - OPMC, Riverview Center, Suite 355, 150 Broadway, Albany, NY 12204-2719. If your license is framed, please remove it from the frame and only send the parchment paper on which vour name is printed. Our of?ce is unable to store framed licenses. If the document(s) are lost, misplaced or destroyed, you are required to submit to this of?ce an af?davit to that effect. Please complete and sign the af?davit before a notary public and return it to the Of?ce of Professional Medical Conduct. Please direct any questions to: NYS DOH - OPMC, Riverview Center, Suite 355, 150 Broadway, Albany. NY 12204-2719, telephone (518) 402-0846. Sincerely, Robert A. Catalano, M.D. Executive Secretary Board for Professional Medical Conduct Enclosure cc: Larry KaSperek, Esq. Easton Thompson Kasperek Shiffrin. LLP. 16 West Main St. Suite 243 Rochester, New York 14614 Empire State Plaza. Corning Tower, Albany. NY i i NEW YORK STATE DEPARTMENT OF HEALTH STATE BOARD FOR PROFESSIONAL MEDICAL CONDUCT BPMC No. 13-039 THE MATTER SURRENDER OF DAVID BLASCZAK. M.D. ORDER Upon the application of (Respondent) DAVID BLASCZAK. MD. to surrender his or her license as a physician In the State of New York. which is made a part of this Surrender Order. it is DATE: ORDERED. that the Surrender. and its terms. are adopted and It is further . ORDERED. that Respondent's name be stricken from the rosteroi physicians in the Slate of New York: it is further ORDERED. that this Order shall be effective Upon issuance by the Board. either . by mailing of a copy of this Surrender Order. either by ?rst class mati to ReSpondent at the address in'ihe attached Surrender of License application or by certi?ed mail to Respondent's attorney. 0R . upon facsimile transmission loRespondent or Respondent's attorney. Whichever is ?rst. SO ORDERED. ARTHUR S. I-IENGERER. MD. Chair State Board for Professional Medical Conduct ?moms-11m?: 1 ?arr-mm:- c-q-II-u o. a nah-.0; ck-u?n-n gun?a 1 NEW YORK STATE DEPARTMENT OF HEALTH STATE BOARD FOR PROFESSIONAL MEDICAL CONDUCT IN THE MATTER SURRENDER 0F 0F - DAVID BLASCZAK, M.D. ORDER DAVID BLASOZAK. M.D., represents that all of the following statements are true: That on or about May 9, 1980. lwas licensed to practice as a physician in the State of New York. and issued License No. 142005 by the New York State Education Department. Mimemweede? -I understand that the New York State Board for Professional Medical Conduct (Board) has charged me with one or more speci?cations of professional misconduct. as set forth in a Statement of Charges, marked as Exhibit which Is attached to and part Of this Surrender of License. I am applying to the State Board for Professional Medical Conduct for permission to surrender my license as a physician in the State of New York on the grounds that i shall not contest the allegations in full satisfaction Of the charges against me. i ask the Board to accept my Surrender of License. and I agree to be bound by all of the terms set forth in attached Exhibit I understand that, if the Board does not accept my Surrender Of License. none of Its terms shall bind me or constitute an admission of any of the acts of misconduct alleged; this application shall not be used against me In any way and shall be kept In strict - 2 con?dence: and the Board?s denial shall be without prejudice to the pending disciplinary proceeding and the Board's ?nal determination pursuant to thePubllc Health 'Law. I agree that. if the Board accepts my Surrender of License. the Chair of the Board shall issue a Surrender Order in accordance with its terms. I agree that this Order shall take effect upon its Issuance by the Board. either by mailing of a capy of the Surrender Order by ?rst class mail to me at the address in this Surrender of License. or to my attorney by certified mail. or upon facsimile transmission to me or my attorney. whichever is ?rst. The Surrender Order. this agreement. and all attached exhibits shall be public documents. with only patient identities or other con?dential information. if any. redacted. As public documents. they may be posted on the Department's website(s). OPMC shall report this action to the National Practitioner Data Bank. the Federation of State Medical Boards. and any other entities that'the Director of OPMC shall deem appropriate. I ask the Board to accept this Surrender of License. which I submit of my own free will and not under duress. compulsion or restraint. In consideration of the value to me of the Board's acceptance of this Surrender of License. allowing me to resolve this matter without the various risks and burdens of a hearing on the merits. knowingly waive my right to contest the Surrender Order for which I apply. whether administratively orJudicially. and i agree to be bound by the Surrender Order. I understand and agree that the attorney for the Department. the Director of the Office of Professional Medical Conduct and the Chair of the State Board for Professional Medical Conduct each retain complete discretion either to enter into [he proposed agreement and Order. based upon my application. or to decline to do so. I further v-m- ?menu-nun? 4.. run?ta cot-cc?- 'i understand and agree that no prior or separate written or oral communication can limit that DATE 6' (F 3 DAVID BLASCZAK. MD. RESPONDENT ?i?ll?'i'il'l? I Iii-10' 4 The undersigned agree to Respondent's attached Surrender of License and Order '1 and to its proposed penalty, terms and conditions. DATE: 4% '2 NCE KASPEREK. Attorney for Respondent 2 43/4,: S. Senior Attorney Bureau of Professional Medical Conduct DATE: A: TH W. SER iS Director Office of Professional Medical Conduct EXHIBIT NEW YORK STATE DEPARTMENT OF HEALTH STATE BOARD FOR PROFESSIONAL MEDICAL CONDUCT IN THE MATTER STATEMENT . or: OF DAVID BLASCZAK, M.D. CHARGES DAVID BLASCZAK. MD. the Respondent, was authorized to practice medicine in New York State on or about May 9. 1980, by the issuance of license number 142005 by the New York State Education Department. FACTUA. ALLEQATIONS A. Respondent. at his of?ce located at 2 West Genesee Street. Clyde, New York 14333. at various times between January 1995 and April 2. 2000. failed to treat at least two patients in a manner within the accepted standard of medical care and/or complete a report of examination for each of these patients. SPECIFICATION 0F CHARGES FIRST SPECIFICATIQLI NEGLIGENCE 0N MORE THAN ONEQCCASION Respondent is charged with committing professional misconduct as de?ned In N.Y. Educ. Law 6530(3) by practicing the profession of medicine with negligence on more than one occasion as alleged in the facts of:. 1. The facts in Paragraph A. arm-r .- . -. -.. ?-noo- .o??pn . Ir-Tr SECONQ SPECIFICATION FAILURE TO MAINTAIN RECORDS Respondent is charged with committing professional misconduct as de?ned In NY. Educ. Law 6530(32) by falling to malntaln a record for each patlent accurately re?ects the evaluation and treatment of the patient. as alleged In the facts of: 2. The facts in Paragraph A. DATE: February 201a Albany. New York HICHAEL A. HISER Deputy Counsel Bureau of Professional Medical Conduct ms -. - .. ?rm-[w - 1? u. .ma EXHIBIT Requirements for Closing a Medical Practice Following a Revocatign. Surrender, leltatign gr Suspension of a Medical License Licensee shall immediately cease and desist from engaging in the practice of medicine in New York State. or under Licensee's New York license. In accordance with the terms of the Order. In addition. Licensee shall refrain from providing an Opinion as to professional practice or its application and from representing that Licensee ls eligible to practice medicine. Within 5 days of the Order?s effective date. Licensee shall deliver Licensee's original license to practice medicine in New York State and current biennial registration to the Office of Professional Medical Conduct (OPMC) at Rivervlew Center. 150 Broadway. Suite 355. Albany. New York 12204-2719. Within 15 days of the Order's effective date. Licensee shall notify all patients of the cessation or limitation of Licensee's medical practice. and shall refer all patients to another licensed practicing physician for continued care. as appropriate. Licensee shall notify. In writing. each health care plan with which the Licensee contracts or is employed. and each hospital where Licensee has privileges. that Licensee has ?ceased medical practice. Within 45 days of the Order's effective date. Licensee shall provide OPMC with written documentation that all patients and hospitals have been noti?ed of the cessation of Licensee's medical practice. Licensee shall make arrangements for the transfer and maintenance of all patient medical records. Within 30 days of the Order's effective date. Licensee shall notify OPMC of these arrangements. including the name. address, and telephone number of an appropriate and acceptable contact person who shall have access to these records. Original records shall be retained for at least 6 years after the last date of service rendered to a patient or. in the case of a minor. for at least 6 years after the last date of service or 3 years after the patient reaches the age of majority. whichever time period is longer. Records shall be maintained in a safe and secure place that is reasonably accessible to former patients. The arrangements shall include provisions to ensure that the Information in the record is kept confidential and is available only to authorized persons. When a patient or a patient's representative requests a copy of the pattent?s medical record. or requests that the original medical record he sent to another health care provider. a copy of the record shall be provided or forwarded at a reasonable cost to the patient (not to exceed 75' cents per page.) Radiographic. sonographlc and similar materials shall be provided at cost. A qualified person shall not be denied access to patient lnfon'natlon solely because of an inability to pay. in the event that Licensee holds a Drug Enforcement Administration (DEA) certificate for New York State. Licensee shall. within 15 days of the Order?s arm 10. effective date. advise the DEA. in writing. of the iicensure action and shall surrender Licensee?s DEA controlled substance privileges for New York State to the DEA. Licensee shall surrender any unused DEA #222 US. Official Order Forms Schedules 1 and 2 for New York State to the DEA. All submissions to the DEA shall be addressed to Diversion Program Manager. New York Field Division. US. Drug Enforcement Administration. 99 Tenth Avenue. New York. NY 10011. Within 15 days of the Order's effective date. Licensee shall return any unused New York State of?cial prescription forms to the Bureau of Narcotic Enforcement of the New York State Department of Health. If no other licensee is providing services at Licensee's practice location. Licensee shall properly dispose of all medications. Within 15 days of the Order's effective date. Licensee shall remove from the public domain any representation that Licensee is eligible to practice medicine. including all related signs. advertisements. professional listings (whether in telephone directories. lntemet or otherwise). professional stationary or billings. Licensee shall not share. occupy. or use office space in which another licensee provides health care services. Licensee shall not charge. receive or share any fee or distribution of dividends for professional services rendered by Licensee or others while Licensee is barred from engaging in the practice of medicine. Licensee may be compensated for the reasonable value of services lawfully rendered. and disbursements incurred on a patient?s behalf. prior to the Order?s effective date. if Licensee Is a shareholder in any professional service corporation organized to engage In the practice of medicine. Licensee shall divest all ?nancial interest in the professional services corporation. in accordance with New York Business Corporation Law. Such divestiture shall occur within 90 days. if Licensee is the sole shareholder in a professional services corporation. the corporation must be dissolved or sold within 90 days of the Order?s effective date. Failure to comply with the above directives may result In a civil penalty or criminal penalties as may be authorized by governing law. Under N.Y. Educ. Law 6512. it Is a Class Felony. punishable by imprisonment for up to 4 years. to practice the profession of medicine when a professional license has been suspended. revoked or annulled. Such punishment is In addition to the penalties for professional misconduct set forth In NY. Pub. Health Law 230-a. which include fines of up to ,$10.000 for each specification of charges of which the Licensee is found guilty. and may include revocation of a suspended license. I Ore-er.